Post on 14-Aug-2020
transcript
9/9/2016
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Brent Curry, Pharm.D.
PGY2 Psychiatric Pharmacy Resident
Seton Shoal Creek Hospital/
The University of Texas at Austin
College of Pharmacy
September 16th, 2016
Current Therapies in the Management
of Parkinson's Disease Psychosis
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Disclosure
Dr. Brent Curry has no relevant conflicts of interest
to disclose
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Learning Objectives After the completion of this presentation, the participant should be able to:
1. Understand the pathophysiology behind Parkinson’s
Disease Psychosis
2. Identify treatment options for the management of
Parkinson’s Disease Psychosis
3. Summarize the research on the newest available
agent for the treatment of Parkinson’s Disease
Psychosis
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Abbreviations AIMS Abnormal Involuntary Movement Scale
BPRS Brief Psychiatric Rating Scale
CGI-S Clinical Global Impression Scale
COMT Catechol-O-methyl transferase
MAO-B Monoamine oxidase B
MMSE Mini-Mental Status Exam
NIMH National Institute of Mental Health
NINDS National Institute of Neurological Disorders and Stroke
NPI Neuropsychiatric Inventory
PANSS Positive and Negative Syndrome Scale
PDP Parkinson’s Disease Psychosis
SAPS Scale for the Assessment of Positive Symptoms
UPDRS Unified Parkinson's Disease Rating Scale 4
Parkinson’s Disease Psychosis
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What is PDP? Part of spectrum of neuropsychiatric disorders in
Parkinson’s disease patients
NINDS/NIMH Criteria for PDP:
Primary diagnosis of Parkinson’s disease
Symptoms occur after onset of Parkinson’s
Presence of at least one psychotic symptom
Recurrent or continuous for one month
Associated with:
Patient morbidity
Caregiver burden
Early mortality
Starkstein SE, Brockman S, Hayhow BD. Psychiatric syndromes in Parkinson’s disease. Curr Opin Psychiatry 2012; 25:468-472.
Chang Anna, Fox SH. Psychosis in Parkinson’s Disease. Drugs 2016; 76:193-1118
Ravina B, Marder K, Fernandez HH, et al. Diagnostic criteria for psychosis in Parkinson's disease. Mov Disord. 2007;22(8):1061-8. 6
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Prevalence of PDP
Prevalence varies widely from 16 % up to 75%
Recent study reported prevalence as 60% in 116
Parkinson’s disease patients in outpatient clinic setting
Similar study in 250 community-based Parkinson’s
disease patients reported prevalence as 26%
In all studies, visual hallucinations are the most
common psychotic symptom
Auditory hallucinations are less common and
delusions even less common
Chang Anna, Fox SH. Psychosis in Parkinson’s Disease. Drugs 2016; 76:193-1118 7
Psychotic Symptoms
Consist of:
Illusions
False sense of presence
Hallucinations (visual and auditory)
Delusions
Insight usually retained initially
The phenomenology of psychotic symptoms unique
to Parkinson’s disease suggest disease-specific
vs. drug-induced etiology
Chang Anna, Fox SH. Psychosis in Parkinson’s Disease. Drugs 2016; 76:193-1118 8
Pathophysiology
Dopaminergic system considered to play pivotal role
in pathophysiology
Link with medications is inconsistent
Complex interplay
Zahodne LB, Fernandez HH. Pathophysiology and treatment of psychosis in Parkinson's disease. Drugs Aging. 2008; 25(8):665-82.
Chang Anna, Fox SH. Psychosis in Parkinson’s Disease. Drugs 2016; 76:193-1118
Risk Factors (Exogenous and
endogenous)
Signaling pathways (multiple
neurotransmitters)
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Pathophysiology
Neuropathology
Neuroimaging
Neurotransmitters
Neuro-signaling pathways
Chang Anna, Fox SH. Psychosis in Parkinson’s Disease. Drugs 2016; 76:193-1118
5-HT
DA
ACH
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Treatment Options for
Parkinson’s Disease Psychosis
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Treatment Considerations
Rule out other causes of psychosis
Relationship between symptoms and medications
difficult to interpret and separate
Limit use of dopaminergic medications symptoms
may persist after medications stopped or reduced
Ensure that motor function is maintained
Continue carbidopa/ levodopa and readjust
Levin J, Hasan A, Höglinger GU. Psychosis in Parkinson's disease. J Neural Transm (Vienna). 2016;123(1):45-50. 12
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Review of Medications Limit use of non-essential non-Parkinson’s disease
medications: Tricyclic antidepressants
Bladder antispasmodics
Benzodiazepines
Muscle relaxants
Opioids
Consider tapering and eliminating: Anticholinergics
MAO-B inhibitors
Amantadine
Dopamine Agonists
COMT inhibitors
Chang Anna, Fox SH. Psychosis in Parkinson’s Disease. Drugs 2016; 76:193-1118 13
Guideline Recommendations
Clozapine should be considered for patients with
Parkinson’s disease and psychosis (Level B)
Associated with agranulocytosis and absolute neutrophil
count must be monitored
Olanzapine should not be routinely considered for
patients with Parkinson’s disease and psychosis (Level B)
Quetiapine may be considered for patients with
Parkinson’s disease and psychosis (Level C)
Miyasaki JM, Shannon K, Voon V, et al. Practice Parameter: evaluation and treatment of depression, psychosis, and dementia in Parkinson disease. Neurology. 2006;66(7):996-1002. 14
Other Recommendations
Seppi K, Weintraub D, Coelho M, et al. The Movement Disorder Society Evidence-Based Medicine Review Update. Mov Disord. 2011; 26 Suppl 3:S42-80.
Efficacy Safety Practice
Implications
Clozapine Efficacious Acceptable risk w/
specialized monitoring
Clinically useful
Olanzapine Unlikely
efficacious
Unacceptable risk Not useful
Quetiapine Insufficient
evidence
Acceptable risk w/o
specialized monitoring
Investigational
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Unified Parkinson's Disease Rating
Scale (UPDRS)
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Part I Evaluation of mentation, behavior, and mood
Part II Self-evaluation of the activities of daily life (ADLs)
including speech, swallowing, handwriting,
dressing, hygiene, falling, salivating, turning in bed,
walking, and cutting food
Part III Clinician-scored monitored motor evaluation
Part IV Complications of therapy
Part V Hoehn and Yahr staging of severity of Parkinson’s
disease
Part VI Schwab and England ADL scale
Ratings Scales
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Scale Measure Rating
Brief Psychiatric
Rating Scale
BPRS Measures psychiatric
symptoms
18-24 symptoms
rated from 1-7
Neuropsychiatric
Inventory
NPI Assesses
neuropsychiatric
symptoms of those
with Alzheimer’s
Behaviors scored
based on frequency,
severity and of
causing caregiver
distress
Positive and
Negative Syndrome
Scale
PANSS Measures symptom
severity of
schizophrenia
30 different
symptoms rated
from 1-7
Scale for
Assessment of
Positive Symptoms
SAPS Measures positive
symptoms in
schizophrenia
Separate symptoms
within 4 domains
rated from 0-5
Clozapine Pollak et al. (2004)
Design Outcomes
4-week, randomized, double-blind, parallel-group comparison of clozapine and placebo
Followed by 12-week clozapine open phase and then 1-month washout period in 60 patients
Clozapine titrated from 6.25 mg/day and increased a maximum of three 12.5 mg steps each week up to a maximum of 50 mg/day
Primary efficacy outcome
was CGI-S
The positive subscore of
PANSS used as secondary
efficacy parameter
UPDRS and MMSE as
safety outcomes
Pollak P, Tison F, Rascol O, et al. Clozapine in drug induced psychosis in Parkinson's disease. J Neurol Neurosurg Psychiatry. 2004; 75:689–695. 18
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Clozapine Pollak et al. (2004)
Results Limits
Mean dose of clozapine was ~36 mg/day at end of double blind period
Mean scores on CGI-S improved by 1.8 for clozapine group compared with 0.6 for placebo group (P = 0.001)
Mean positive subscore of PANSS improved by 5.6 for clozapine group and 0.8 for placebo group (P < 0.0001)
19/25 (76%) experienced
a relapse within one month
of washout period
The UPDRS motor and
MMSE mean scores did not
change significantly in
either group
Pollak P, Tison F, Rascol O, et al. Clozapine in drug induced psychosis in Parkinson's disease. J Neurol Neurosurg Psychiatry. 2004; 75:689–695. 19
Clozapine vs. Quetiapine Morgante et al. (2004)
Design Outcomes
12-week randomized, rater-blinded trial
40 patients with PDP treated with either clozapine (n=20) or quetiapine (n=20)
Clozapine started at 6.25 mg/day and titrated up to 50 mg/day
Quetiapine started at 25 mg/day and titrated up to 200 mg/day
Severity of psychosis
assessed using:
BPRS total, BPRS 5-Items,
and CGI-S
Motor impairment
assessed using UPDRS-III
and dyskinesias assessed
using AIMS
Morgante L, Epifanio A, Spina E, et al. Quetiapine and clozapine in parkinsonian patients with dopaminergic psychosis. Clin Neuropharmacol. 2004;27:153–156. 20
Demographic and Clinical Features of the
Patients Completing the Study
21 Morgante L, Epifanio A, Spina E, et al. Quetiapine and clozapine in parkinsonian patients with dopaminergic psychosis. Clin Neuropharmacol. 2004;27:153–156.
Features Quetiapine
(n=20)
Clozapine
(n=20)
Differences Between
Treatment Groups
BPRS total Baseline 37.1 ± 6.1 37.4 ± 5.4 NS
Endpoint 38.7 ± 4.2 26.7 ± 3.6 NS
BPRS (5
items)
Baseline 15.5 ± 3.4 16.4 ± 2.6 NS
Endpoint 8.4 ± 1.5 8.5 ± 2.0 NS
CGI-S Baseline 3.6 ± 0.7 3.8 ± 0.8 NS
Endpoint 2.1 ± 0.6 1.9 ± 0.6 NS
UPDRS-III Baseline 53 ± 11 58 ± 9.4 NS
Endpoint 54 ± 11 56.7 ± 9.2 NS
AIMS Baseline 7.8 ± 2 7.2 ± 2.1 NS
Endpoint 6 ± 1.3 5.4 ± 1.3 NS
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Clozapine vs. Quetiapine Morgante et al. (2004)
Results Limits
Mean dosages of 91 mg/day in quetiapine arm and 26 mg/day in clozapine arm
Psychosis scores improved significantly in both groups as recorded on both BPRS and CGI-S (P < .001)
UPDRS-III scores remained stable in both groups
Statistically significant decrease in dyskinesia (P < 0.05) in both groups
Motor worsening was
reported in 3 patients on
quetiapine
5/40 (12.5%) patients
dropped out due to adverse
effects
3 patients in clozapine
arm, 2 patients in
quetiapine arm
Morgante L, Epifanio A, Spina E, et al. Quetiapine and clozapine in parkinsonian patients with dopaminergic psychosis. Clin Neuropharmacol. 2004;27:153–156. 22
Clozapine vs. Quetiapine Merims et al. (2006)
Design Outcomes
22-week parallel-group, randomized controlled trial comparing quetiapine (n = 13) and clozapine (n = 14)
Dose adjustments gradually increased every 2 weeks during the first 10 weeks (maximal 50 mg/day for clozapine and 150 mg/day for quetiapine) until psychosis considered under “satisfactory control”
Primary endpoints were
selected items
(hallucinations and
delusions) from NPI and
CGI-C questionnaires
Assessments done by a
blinded neuropsychologist
Motor worsening assessed
using UDPRS
Merims D, Balas M, Peretz C, Shabtai H, Giladi N. Rater-blinded, prospective comparison: quetiapine versus clozapine for Parkinson's disease psychosis. Clin
Neuropharmacol. 2006;29:331–337. 23
The CGIC (mean scores) from baseline
scores over time in the 2 treatment groups
Merims D, Balas M, Peretz C, Shabtai H, Giladi N. Rater-blinded, prospective comparison: quetiapine versus clozapine for Parkinson's disease psychosis. Clin
Neuropharmacol. 2006;29:331–337. 24
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Hallucinations and delusions frequency (mean NPI
scores) over time in both treatment groups
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Merims D, Balas M, Peretz C, Shabtai H, Giladi N. Rater-blinded, prospective comparison: quetiapine versus clozapine for Parkinson's disease psychosis. Clin
Neuropharmacol. 2006;29:331–337.
Clozapine vs. Quetiapine Merims et al. (2006)
Results Limits
11 patients (~80%) from each arm reached “satisfactory control”
Mean dose was 91 mg/day for quetiapine and 13 mg/day for clozapine
No worsening in motor symptoms as measured by UPDRS in either treatment arm
Only 7/14 patients randomized to receive clozapine and 9/13 randomized to receive quetiapine completed the study
One patient developed severe neutropenia with clozapine and 2 others discounted due to decreases in leukocytes
Merims D, Balas M, Peretz C, Shabtai H, Giladi N. Rater-blinded, prospective comparison: quetiapine versus clozapine for Parkinson's disease psychosis. Clin
Neuropharmacol. 2006;29:331–337. 26
Quetiapine Study Design Intervention Results Limits
Ondo et
al.
(2005)
Double-
blind,
placebo-
controlled,
parallel-
group
study
Patients randomized
in a 2:1 ratio to 12
weeks of treatment
with quetiapine (n =
21, up to 200
mg/day) or placebo
(n = 10)
None of the
hallucinations,
psychosis, or
motor
impairment
assessments
changed
significantly on
quetiapine
4/17 (24%)
patients on
quetiapine
that
completed
study reported
subjective
worsening
Rabey et
al.
(2007)
Double-
blind,
placebo-
controlled,
parallel-
group
12-week trial
investigating total of
58 patients
(quetiapine n = 30,
mean dosage 119.2
± 56.4 mg/day;
placebo n = 28)
Compared to
placebo none of
BPRS or CGI-S
scores
changed
significantly on
quetiapine
High dropout
rate of 45% (n
= 26) primarily
due to lack of
efficacy
Ondo W, Tintner R, Voung K, Lai D, Ringholz G. Double-blind, placebo-controlled, unforced titration parallel trial of quetiapine for dopaminergic-induced hallucinations in
Parkinson's disease. Mov Disord. 2005; 20:958–963.
Rabey J, Prokhorov T, Miniovitz A, Dobronevsky E, Klein C. Effect of quetiapine in psychotic Parkinson's disease patients. Mov Disord. 2007; 22:313–318.
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Olanzapine Study Design Intervention Results Limits
Breier et
al.
(2002)
2 placebo-
controlled,
double-blind,
parallel-group
randomized
controlled
trials
Patients randomized
1:1 in the U.S. study
(n= 83), and 2:1 in
the European study
(n= 77) to receive
olanzapine (mean
dosage 4.2 mg ± 2.6
and 4.1 mg ± 2.0,
respectively) or
placebo
No significant
treatment
group
differences in
any psychosis
ratings on
BPRS were
found in either
study
Motor function
worsened
significantly in
patients on
olanzapine
compared to
placebo as
measured by
UPDRS
Ondo et
al.
(2002)
Double-blind,
placebo-
controlled,
parallel-group,
randomized
controlled trial
30 patients with PDP
underwent 9 weeks
of treatment with
olanzapine (mean
dosage 4.6 mg/day)
or placebo (2:1 ratio)
Failed to detect
significant
differences
between
olanzapine and
placebo in any
of psychosis
measures
Significant
worsening of
UPDRS motor
scores in the
olanzapine arm
Breier A, Sutton V, Feldman P, et al. Olanzapine in the treatment of dopamimetic-induced psychosis in patients with Parkinson's disease. Biol Psychiatry. 2002; 52:438–445.
Ondo W, Levy J, Vuong K, Hunter C, Jankovic J. Olanzapine treatment for dopaminergic-induced hallucinations. Mov Disord. 2002; 17:1031–1035. 28
Other Atypical Antipsychotics Open-label trial involving 14 patients with PDP treated
with aripiprazole
6/14 (43%) patients experienced improvement in psychosis
8/14 (57%) patients discontinued treatment due adverse effects
4-week, randomized, single-blind, open-label, parallel comparison of ziprasidone and clozapine in 16 patients with PDP
14/16 patients completed the study 8 patients on clozapine and 6 patients on ziprasidone
Ziprasidone seemed to be at least as effective as clozapine as psychotic symptoms reduced in both groups
Friedman JH, Berman RM, Goetz CG, et al. Open-label flexible-dose pilot study to evaluate the safety and tolerability of aripiprazole in patients with psychosis associated with Parkinson’s
disease. Movement Disorders. 2006; 21 (12):2078–81.
Pintor L, Valldeoriola F, Bailles E et al. Ziprasidone versus clozapine in the treatment of psychotic symptoms in Parkinson Disease. Clin Neuropharm 2012;35: 61-66 29
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Mechanism of Action
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Acts as an inverse agonist and antagonist
High affinity for 5-HT2A receptors and low affinity for
5-HT2C receptors
No affinity for 5-HT2B, dopaminergic (including D2),
muscarinic, histaminergic, or adrenergic receptors
Nuplazid (pimavanserin) [prescribing information]. San Diego, CA: Acadia Pharmaceuticals Inc: April 2016.
Pharmacokinetics
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Distribution: Vd: 2,173 L
Protein binding: ~95%
Metabolism: Primarily via CYP3A4 and CYP3A5;
forms active N-desmethylated metabolite
Elimination half-life:
Pimavanserin: ~57 hours
N-desmethylated metabolite: ~200 hours
Time to peak: 6 hours (median: 4 to 24 hours)
Excretion: Feces (<2%); urine (<1% as unchanged)
Nuplazid (pimavanserin) [prescribing information]. San Diego, CA: Acadia Pharmaceuticals Inc: April 2016.
Dose: 34 mg/day taken with or without food
Dose adjustment needed with concomitant therapy of
strong CYP3A4 inhibitors/ inducers
Not recommended in severe renal/ hepatic
impairment
AEs: CNS depression, orthostatic hypotension, QTc-
prolongation, peripheral edema, confusion,
hallucinations, abnormal gait, nausea, constipation
Nuplazid (pimavanserin) [prescribing information]. San Diego, CA: Acadia Pharmaceuticals Inc: April 2016. 33
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Studies Evaluating Pimavanserin
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Meltzer et al. (2010) – Phase II study
Design Outcomes
Double-blind,
randomized multi-center
28-day study
Tolerability and efficacy
of pimavanserin (doses
up to 60 mg/day)
compared to placebo in
60 patients with PDP
Antipsychotic efficacy
evaluated using SAPS
SAPS total domain score
was chosen as principal
outcome measure for
efficacy
Motor function evaluated
using UPDRS
Meltzer HY, Mills R, Revell S, et al. Pimavanserin, a serotonin(2A) receptor inverse agonist, for the treatment of parkinson's disease psychosis.
Neuropsychopharmacology. 2010;35(4):881-92. 35
Meltzer et al. (2010): Mean (SD) Baseline and Day 28 SAPS Scores
Change from Baseline (Screening Visit) to Day 28
Parameter Pimavanserin
(n=24)
Placebo
(n=28)
LS mean
difference
95%
CI
P-
value
Effect
size
Base Day 28 Base Day 28
SAPS total
(H+D)
domain
score
16.7
(7.45)
11.0
(11.09)
17.9
(11.79)
16.8
(14.35)
−4.6 −10.0,
0.7
0.09 0.56
Meltzer HY, Mills R, Revell S, et al. Pimavanserin, a serotonin(2A) receptor inverse agonist, for the treatment of parkinson's disease psychosis.
Neuropsychopharmacology. 2010;35(4):881-92. 36
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Meltzer et al. (2010) – Phase II study
Results Limits
Pimavanserin did not
differentiate from
placebo with regard to
motor impairment,
sedation, hypotension, or
other side effects
Principal measures of
efficacy of antipsychotic
response, the SAPS total
domain score, only
showed a trend
Meltzer HY, Mills R, Revell S, et al. Pimavanserin, a serotonin(2A) receptor inverse agonist, for the treatment of parkinson's disease psychosis.
Neuropsychopharmacology. 2010;35(4):881-92. 37
Cummings et al. (2014) – Phase III study
Design Outcomes
6 week, randomized,
double-blind, placebo-
controlled
After 2 week non-
pharmacological lead-in
phase, patients randomly
allocated (1:1) to receive
pimavanserin 40 mg/day
(n= 90) or placebo
(n=95)
Antipsychotic benefit
evaluated using SAPS-PD
Safety and tolerability in
all patients
Cummings J, Isaacson S, Mills R, et al. Pimavanserin for patients with Parkinson's disease psychosis: a randomized, placebo-controlled phase 3 trial. Lancet
2014;383:533-40. 38
Cummings et al. (2014) – Phase III study
Results Limits
Pimavanserin was associated with a -5.79 decrease in SAPS-PD scores compared with -2.73 for placebo (difference -3.06, 95% CI -4.91 to -1.20; P =0.001)
Pimavanserin was well tolerated with no significant safety concerns or worsening of motor function
10 patients in the
pimavanserin group
discontinued because of
an adverse event
4 patients experiencing
hallucinations within 10
days of start of
pimavanserin
Cummings J, Isaacson S, Mills R, et al. Pimavanserin for patients with Parkinson's disease psychosis: a randomized, placebo-controlled phase 3 trial. Lancet
2014;383:533-40. 39
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Yasue et al. (2015)
Design Outcomes
Meta-analysis of
randomized placebo-
controlled trials
Included 417 drug-
treated and 263
placebo-treated PDP
patients over 4 trials (2
unpublished trials)
Comparison of SAPS-H+D
scores (primary)
Comparison of SAPS-H,
SAPS-D, UPDRS-II+III
scores, discontinuation
rates, and individual
adverse events
(secondary)
Yasue I, Matsunaga S, Kishi T, Fujita K, Iwata N. Serotonin 2A Receptor Inverse Agonist as a Treatment for Parkinson's Disease Psychosis: A Systematic Review and
Meta-analysis of Serotonin 2A Receptor Negative Modulators. J Alzheimers Dis. 2015;50(3):733-40 40
Yasue et al. (2015)
Results Adverse Events
Pimavanserin significantly decreased SAPS-H+D scores compared to placebo (difference -2.26, 95% CI -3.86 to -0.67; P = 0.005)
Pimavanserin was superior to placebo for reducing SAPS-H and SAPS-D scores
Pimavanserin was associated with less orthostatic hypotension than placebo
There were no significant differences in rates of all-cause discontinuation, adverse events, death, UPDRS scores, and incidences of individual adverse events
Yasue I, Matsunaga S, Kishi T, Fujita K, Iwata N. Serotonin 2A Receptor Inverse Agonist as a Treatment for Parkinson's Disease Psychosis: A Systematic Review and
Meta-analysis of Serotonin 2A Receptor Negative Modulators. J Alzheimers Dis. 2015;50(3):733-40 41
A Review of the Treatment Options
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Antipsychotic
Medication
Decrease in
Psychotic
Symptoms
Lack of Motor
Adverse Effects
Clozapine +
+
Quetiapine + / --
+ / --
Olanzapine ---
---
Pimavanserin + / --
+
+ = Positive outcomes in trials +/-- = Mixed outcomes in trials -- = Negative outcomes in trials
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Treatment Considerations with
Pimavanserin
Cost 17 mg (60): AWP = $2,340
Currently only available through restricted access program and limited wholesalers
Significant drug-drug interactions with CYP 3A4 inducers and inhibitors
Avoid use in those with QT prolongation or on other drugs that can prolong QT interval
Concerns about safety including the rates for severe adverse effects and deaths
Post hoc analysis of open-label extension study showed significant increase in mortality of those taking concurrent antipsychotics (IRR 4.20, 95% CI 2.13-7.96)
Ballard C, Isaacson S, Mills R, et al. Impact of Current Antipsychotic Medications on Comparative Mortality in People With Parkinson Disease Psychosis. J Am Med Dir Assoc.
2015;16(10):898.e1-7. 43
Place in Therapy for Pimavanserin
No other FDA-approved drugs for PDP
Other treatment options have several limitations and
concerns for safety and adverse effects
Unique mechanism of action opens door for further
research
Potential to be first choice treatment option for PDP
Hermanowicz S, Hermanowicz N. The safety, tolerability and efficacy of pimavanserin tartrate in the treatment of psychosis in Parkinson’s disease. Expert Rev Neurother. 2016;
16(6):625-33 44
Management of PDP Rule out other
causes of psychosis
Limit use of dopaminergic
agents
Clozapine
(low-dose)
Pimavanserin (34 mg daily)
Quetiapine
(low-dose)
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Patient Case
In the geriatric clinic where you are the clinical pharmacist, a provider approaches you asking for a recommendation for one of his patients after a recent visit. The patient is a 70-year-old man with a 10-year history of Parkinson’s disease being treated with carbidopa/levodopa (25/250-mg tablets PO Q4H) and pramipexole (1.5 mg PO Q8H). He had not been experiencing motor fluctuations. But during the visit, the patient remarked that “the leprechauns had been coming out more than usual in the few last weeks.” The patient’s family explained that he had been seeing small people dressed in costumes sitting in his living room over the last few months. The patient thought “the leprechauns” were amusing and did not report being bother by these hallucinations.
Adopted from: Salter BC, Anderson KE, Weiner WJ. Psychosis in Parkinson's disease: case studies. Neurol Clin. 2006;24(2):363-9. 46
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Acknowledgements
Dr. Brent Curry would like to thank the following
people for their assistance in preparation of this
presentation:
Lisa Mican, Pharm.D., BCPP
Kattura, Rania, Pharm.D., MsPhr, BCPP
Melissa Lewis, Pharm.D., BCPP
Kasey Leggette Peña, Pharm.D.
Stephen Saklad, Pharm.D., BCPP
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